Elite Chiropractic & Rehab
2422 E. Washington St#202
Bloomington, IL 61704

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information

Personal Information
Contact Information
Feet Inches

(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)


How did you find out about our office?

Did you hear about our office from an advertisement?

If Yes, Where:

Did you hear about our office from a phone or professional directory?

If Yes, Where:

Employment Information

Insurance & Payment for Care

Primary Insurance
Secondary Insurance

If an auto accident, please provide:

Reason for this Visit

If you're only here for chiropractic wellness services please skip this section.

Does this concern interfere with:


Goals for Your Care

People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible.


*** PATIENT CONSENT ***For use and/or disclosure of Protected Health Information (PHI)To carry out Treatment, Payment and Healthcare OperationsI hereby state that by signing this Consent, I acknowledge and agree as follows:1. The Practice’s Privacy Notice has been provided to me prior to my signing this Consent. The Privacy Notice includes a complete description of the uses and/or disclosures of my protected health information (“PHI”) necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out its health care operations. The Practice explained to me that the Privacy Notice would be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this Consent.2. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law. 3. The Practice’s “Notice of Privacy Practices” is also posted in the office reception area. I may also request a copy from this office at any time via US Mail.4. This Notice of Privacy Practices also describes my rights and the duties of this office with respect to my protected health information.5. I understand that, and consent to, the following appointment reminders that will be used by the Practice: a) a postcard mailed to me at the address provided by me; and b) telephoning my home and leaving a message on my answering machine or with the individual answering the phone. 6. The Practice may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct its specific health care operations.7. I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operations. However, the Practice is not required to agree to any restrictions that I have requested. If the Practice agrees to a requested restriction, then the restriction is binding on the Practice.8. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Practice has already taken action in reliance on this consent.9. I understand that if I do not sign this consent or revoke consent at any time, the Practice has the right to refuse to treat me.10. I understand and consent to the following other types of correspondence from this office:a.) a birthday card may be mail to me at the address I provided; andb.) I may receive periodic mailings of general health information in the form of a newsletter*** PATIENT RESPONSIBILITY ***I understand and agree that I am financially responsible for all charges for any and all services rendered. This includes any chiropractic treatment or therapy ordered by the physician. I understand that while my insurance may confirm my benefits, confirmation of benefits is not a guarantee of payment and that I am responsible for any unpaid balance.I understand and agree that it is my responsibility to know if my insurance has any deductible, copayment, co-insurance, out-of-network, usual and customary limit, prior authorization requirements or any other type of benefit limitation for the services I receive and I agree to make payment in full.I agree to inform the office of any changes in my insurance coverage. I understand that I may be charged $25.00 for any missed appointments without a proper 24 hour notice, which may be charged to my credit card on file on the date of missed service. If my insurance has changed or is terminated at the time of service, I agree that I am financially responsible for the balance in full. In the event of an unpaid balance, my credit card on file may be automatically charged for any past due balance prior to collection activity. In the event my account is sent to collections, there is a 1.5% monthly late charge assessed on all balances after 90 days past due. Checks, which are declared non-sufficient funds, will be charged a $25.00 service fee. Also, the undersign agrees to pay a collection fee of 33% of the total owed when sent to collections, all attorney fees and court costs incurred by the creditor. I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I understand. I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. By submitting this application I understand that I am bound by all of the terms and conditions previously mentioned.Electronic submission of this form will constitute agreement to the above terms and conditions.

Name of the Insured:
(Please Print)
Patient's/Guardian's signature:

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